title: Hostile clinician behaviours in the nursing work environment and implications for patient care: a mixed-methods systematic review.
abstract: BACKGROUND
  Although there is a sizeable body of evidence regarding the nature of hostile behaviours among clinicians in the nursing workplace, what is less clear is the nature of the relationship between these behaviours and patient care. To inform the development of appropriate intervention strategies we examine the level of evidence detailing the relationships between hostile clinician behaviours and patient care.
  
  
  METHODS
  Published qualitative and quantitative studies that examined hostile clinician behaviours and patient care were included. Quality assessment, data extraction and analysis were undertaken on all included studies. The search strategy was undertaken in July and August 2011 and comprised eight electronic databases (CINAHL, Health Collection (Informit), Medline (Ovid), Ovid Nursing Full Text, Proquest Health and Medicine, PsycInfo, Pubmed and Cochrane library) as well as hand searching of reference lists.
  
  
  RESULTS
  The search strategy yielded 30 appropriate publications. Employing content analysis four themes were refined: physician-nurse relations and patient care, nurse-nurse bullying, intimidation and patient care, reduced nurse performance related to exposure to hostile clinician behaviours, and nurses and physicians directly implicating patients in hostile clinician behaviours.
  
  
  CONCLUSIONS
  Our results document evidence of various forms of hostile clinician behaviours which implicate nursing care and patient care. By identifying the place of nurse-nurse hostility in undermining patient care, we focus attention upon the limitations of policy and intervention strategies that have to date largely focused upon the disruptive behaviour of physicians. We conclude that the paucity of robustly designed studies indicates the problem is a comparatively under researched area warranting further examination.
authors.affiliation: School of Health and Human Sciences, Southern Cross University, PO Box 157, Lismore 2780, Australia. marie.hutchinson@scu.edu.au.
authors.forename: Marie
authors.initials: M
authors.lastname: Hutchinson
authors.forename: Debra
authors.initials: D
authors.lastname: Jackson